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Additional Financial Assistance Form

The Pink Pumpkin Project Breast Cancer Assistance Program provides support to those struggling with expenses during their treatment.

Program Overview

  • Assistance is based on our funding at the time of the application.

  • We try to process all completed applications within 14 business days of receipt.

  • All applications are processed in the order in which they were received.

  • If you did not receive a confirmation email from us, please email: to confirm receipt.


  • Funds may be used for daily living costs such as rent, food, gas and utilities. Funds may also be used for medical expenses.

  • Payments for utilities, rent/mortgage, and medical expenses will be made directly to the company name.

  • We do not disburse cash payments. Payments excluding those made to companies will be in the form of a visa debit card.


  • You must currently be in treatment for breast cancer.

  • You must live within our “pink circle” (please see the circle on the homepage).

  • You have not exceeded our “fund cap”.

Applicant Information

Please select your Most urgent care-related financial need:

Select One
Upload File

**If rent/mortgage, utility, or medical bill, please attach a copy of the bill being requested**

***Please note that we DO NOT GUARANTEE we will pay the complete amount requested***

Thanks for submitting!

Or download the form directly:

You will receive a confirmation email for your submission, if you do not, please submit the form again.


You will be contacted within 7-14 business days, once the nomination form has been reviewed.


Please know, we understand how difficult this is for those going thru this and we greatly appreciate you caring enough to nominate them for assistance.


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